DRAFT ONLY-Clarification of Ligature Risk Interpretive Guidelines – FOR ACTION
This draft policy memorandum would update S&C: 18-06-Hospitals released by the Centers for Medicare & Medicaid Services (CMS)
on December 8, 2017.
• This Memo is Being Released in Draft: We seek comment on these draft revised policies by June 17, 2019 (60 days from the
date of this release).
• Ligature Risks Compromise Patients’ Right to Receive Care in a Safe Setting: The care and safety of psychiatric patients
at risk of harm to themselves or others, and the staff providing care are our primary concerns. The comprehensive ligature
risk interpretive guidance in the CMS State Operations Manual (SOM) Appendix A for Hospitals is being revised to provide direction
and clarity for CMS Regional Offices, State Survey Agencies, accrediting organizations and hospitals.
• Ligature Risk Extension Request Process Update: The SOM Chapter 2, Section 2728G - Major Deficiencies Requiring Long-Term
Correction in Psychiatric Hospitals and Hospital Psychiatric Units, Ligature Risk-Ligature Risk Extension Requests is also
being updated. The section describes the process for deemed and non-deemed hospitals to request a ligature risk extension
based on evidence of hardship and inability to complete necessary renovations within 60 days.